Failing to bill out over $1.5 million in claims? Clearly, the provider community is frustrated
Reform will fail when practitioners are not getting paid for legitimate work they do. Paying healthcare practitioners fairly is the crux of healthcare payment reform. Here is a brief synopsis of how methods to reign in physician compensation have always failed and nothing was ever solved through cost-shifting or cost-sharing. In brief, various attempts "Reforming Medicare's Physician Payment System" [N Eng J Med] have fallen flat.
It is unclear in the U.S. if Cost Effectiveness Research (CER) studies are compelling enough to overturn insurer's coverage decisions or reduce well-established procedures--Beware the status quo
Much of the work on health disparities and inequities in access focuses on comparisons between the insured and those without coverage. It should come as no surprise that the uninsured come out wanting and “Uninsurance is associated with mortality.” Furthermore, Uninsured persons have less access to services, suffering worse health outcomes than that of the insured. Breast Cancer patients seem to have a 30-50% higher mortality rate then those without cancer.
Aetna refused to pay for a visit of a child with a probable goiter and strong family history who needed diagnostic lab tests—they do not accept rule-outs. Not long ago, Oxford levied a $50 deductible and $25 co-pay for the most efficacious eardrop we have in our armamentarium; Reason? This drop, containing an antibiotic and a steroid was not available generically; they were forcing me to use a plain ear drop – not what the doctor ordered! Mental Health Parity; Let the HMO's Be Damned!
Coding systems that support clinical decision-making, 'measurement and management,' communication, especially about transitions of care and outcomes (acuity-adjusted) become the modus operandi of the new Managed Care.
We can sustain recent successes that increase the number of insured, improve the value of health care, reduce waste, and entitlement costs. [Ref.–the Accountable Care–Act (ACA)]. In addition, "healthcare costs can be controlled if we focus on and implement adequately risk-adjusted payment incentives* for a small number of outcomes. A small number of outcomes is critical for consumer understanding and will facilitate healthcare delivery change.
The health insurance and managed care industries are strange bedfellows. Health insurance, however, seems to work better for health insurance companies than patients, by and large. They, the insurers "like to cite figures showing that 87 cents of every dollar in premiums is spent on medical claims. But a new Senate analysis suggests that for-profit insurance companies are spending much less than that, especially for policies sold to individuals and small businesses.
Would you care to see efficacy in new product development where the reduction in mortality for patients so treated takes a back seat to 'The cheaper is first" rule. In this example, metformin is standard therapy; the more efficacious Lilly product, must wait in the wings. Macrovascular Efficacy: Microvascular Efficacy: Why doesn't Dr. Jones' opinion about therapeutic efficacy really matter? What if the patient won't or can't take the test or medicine?
The "areas in which the proper reform measures could generate savings that could pay for universal coverage" include, but are not limited to unecessary and presumably unhelpful care, fraud and from the perspective of the physician, extraneous administrative expenses. Unnecessary care is believed to be responsible for as much as 30% of health care spending,2 or up to $830 billion this year alone.